Reported Personality Traits and Histories of Childhood Maltreatment in Borderline Personality Disorder and Bipolar 2 Disorder: A Comparative Study.

This study compared borderline personality disorder (BPD) and bipolar 2 disorder (BP 2 disorder) with respect to reported childhood trauma and Five-Factor personality traits using the Childhood Trauma Questionnaire (CTQ) and the NEO Five-Factor Inventory (NEO-FFI). Participants were 50 men and women, aged 18-45, with DSM-5-diagnosed BPD and 50 men and women in the same age group with DSM-5-diagnosed BP 2 disorder. Participants could not meet criteria for both BPD and BP 2 disorder. Borderline participants had significantly higher scores on the neuroticism subscale and significantly lower scores on the agreeableness subscale of the NEO-FFI. After correction for multiple comparisons, there were no between-group differences on CTQ scores. Study results suggest that BPD and BP 2 disorder differ primarily with respect to underlying temperament/genetic architecture and that environmental factors have only a limited role in the differential etiologies of the two disorders.

Levels of Acceptance and Forgiveness Reported by Patients With BPD and Personality-Disordered Comparison Subjects Over 20 Years of Prospective Follow-Up.

This study had two objectives: to determine the levels of acceptance and forgiveness reported by patients with borderline personality disorder (BPD) and personality-disordered comparison subjects and by recovered versus non-recovered patients with BPD over 20 years of prospective follow-up. Levels of acceptance and forgiveness were reassessed every 2 years. Patients with BPD reported levels of these states that were approximately 70% lower than comparison subjects at baseline. These states increased significantly over time for patients with BPD but not for comparison subjects. Recovered patients with BPD reported approximately three times the levels of these states than non-recovered patients with BPD. These levels increased for both groups over time; one state (accepting of myself) increased at a significantly steeper rate for recovered patients with BPD. These results suggest that patients with BPD report becoming more accepting and forgiving over time. Additionally, recovery status is significantly associated with increasing time in these states.

Amygdala Resting State Connectivity Differences between Bipolar II and Borderline Personality Disorders.

BACKGROUND: Borderline personality disorder (BPD) and bipolar II disorder (BD II) have significant clinical overlap, leaving the potential for diagnostic inaccuracies and inadequate treatment recommendations. However, few studies have probed for clinical and neurobiological differences between the two disorders. Clinically, some prior studies have linked BPD with greater impulsivity and more frequent negative affective shifts than BD II, whereas previous neuroimaging studies have highlighted both similar and distinct neural abnormalities in BPD and BD II. Notably, no prior study has specifically targeted cortico-limbic neural differences, which have been hypothesized to underlie these core clinical differences. METHODS: Individuals with BPD (n = 14) and BD II (n = 15) completed various clinical measures and a resting state functional imaging scan at 3T. Whole-brain amygdala resting state functional connectivity (RSFC) was compared between the two groups. RESULTS: Relative to the BD II group, BPD participants reported significantly higher levels of impulsivity, trait anxiety, more frequent negative affective shifts, greater interpersonally reactive affective instability, lower overall functioning, and were characterized by lower amygdala-middle frontal gyrus RSFC. Lower amygdala-middle frontal gyrus RSFC was associated with greater impulsivity, trait anxiety, affective shifts, interpersonal affective reactivity, and functional impairment. LIMITATIONS: The current study consisted of small sample sizes and lacked a control group. CONCLUSIONS: This preliminary study suggests that amygdala-frontal RSFC may distinguish BPD from BD II. These results may guide future work aimed at identifying neural markers that can help disentangle these two disorders, leading to greater diagnostic accuracy and appropriate treatment implementation.

The 24-year course of major depression in patients with borderline personality disorder and personality-disordered comparison subjects.

BACKGROUND: This study had two main objectives. The first was to detail the prevalence of major depressive disorder over 24 years of follow-up for both patients with borderline personality disorder (BPD) and comparison subjects with other personality disorders (OPD). The second was to determine time-to-remission, recurrence, and new onset of major depression among these two groups of patients. METHODS: The SCID-I was administered to 290 borderline inpatients and 72 personality-disordered comparison subjects during their index admission. It was also re-administered at 12 contiguous two-year follow-up periods. RESULTS: The prevalence of major depression was significantly higher for borderline patients over time but declined significantly over time for those in both study groups. In terms of time to events, 93% of borderline patients meeting criteria for major depression at baseline experienced a two-year remission by the time of the 24-year follow-up. Recurrences were about as common (90% for those with remitted major depression). New onsets of major depression were also very common (86% for those without major depression during their index admission). LIMITATIONS: Results may not pertain to less severely ill patients with BPD and those in less treatment. CONCLUSIONS: Taken together, the results of this study suggest that the remitting-recurring course of major depression in borderline patients is very similar to the course of major depression in those with other types of personality disorder and those for whom major depression is their primary disorder.

Description and prediction of time-to-attainment of excellent recovery for borderline patients followed prospectively for 20 years.

One purpose of this study was to determine the cumulative rates of excellent recovery for borderline patients and axis II comparison subjects followed prospectively for 20 years. Another purpose was to find the best set of baseline predictors of excellent recovery for borderline patients. A total of 290 inpatients meeting rigorous criteria for borderline personality disorder and 72 axis II comparison subjects completed semistructured interviews and self-report measures during their index admission. Subjects were reassessed prospectively over 10 contiguous two-year waves of follow-up. Thirty-nine percent of borderline patients and 73% of personality-disordered comparison subjects met our operationalized definition of excellent recovery (concurrent remission of borderline or another primary personality disorder, good social and full-time vocational functioning, and absence of an axis I disorder associated decreased social and/or vocational functioning). Five variables formed our multivariate predictive model of excellent recovery for borderline patients: higher IQ, good childhood work history, good adult vocational record, lower trait neuroticism, and higher trait agreeableness. The results of this study suggest that complete recovery is difficult for borderline patients to achieve even over long periods of time. They also suggest that competence displayed in both childhood and adulthood is the best predictor of this important outcome.

Fluidity of the Subsyndromal Phenomenology of Borderline Personality Disorder Over 16 Years of Prospective Follow-Up.

OBJECTIVE: The purpose of this study was to determine the cumulative rates of 2- and 4-year remission, and the recurrences that follow them, of 24 symptoms of borderline personality disorder over 16 years of prospective follow-up. METHOD: A total of 290 inpatients meeting rigorous criteria for borderline personality disorder and 72 axis II comparison subjects were assessed during their index admission using a series of semistructured diagnostic interviews. The same instruments were readministered at eight contiguous 2-year time periods. RESULTS: The 12 acute symptoms (e.g., self-mutilation, help-seeking suicide attempts) of borderline personality disorder were more likely to remit for a period of 2 years and for a period of 4 years than the 12 temperamental symptoms (e.g., chronic anger/frequent angry acts, intolerance of aloneness) of this disorder. They were also less likely to recur after a remission lasting 2 years or a remission lasting 4 years. CONCLUSIONS: Taken together, the symptoms of borderline personality disorder are quite fluid, with remissions and recurrences being common. However, the more clinically urgent acute symptoms of borderline personality disorder seem to have a better prognosis than the less turbulent temperamental symptoms of the disorder.

The course of marriage/sustained cohabitation and parenthood among borderline patients followed prospectively for 16 years.

The purpose of this study was to determine the rate of marriage/sustained cohabitation and parenthood reported by recovered and nonrecovered borderline patients, the age first undertaken, and the stability of these relationships. Borderline patients were interviewed about these topics during their index admission and eight times over 16 years of prospective follow-up. Recovered borderline patients were significantly more likely than nonrecovered borderline patients to have married/lived with an intimate partner and to have become a parent. In addition, they first married/cohabited and became a parent at a significantly older age. They were also significantly less likely to have been divorced or ended a cohabiting relationship. In addition, they were significantly less likely to have given up or lost custody of a child. Taken together, the results of this study suggest that stable functioning as a spouse/partner and as a parent are strongly associated with recovery status for borderline patients.

Treatment rates for patients with borderline personality disorder and other personality disorders: a 16-year study.

OBJECTIVE: The goal of this study was to document the use of 16 treatment modalities reported by 290 patients with borderline personality disorder and 72 patients with other axis II disorders over 16 years of prospective follow-up. METHODS: This study built upon previous findings of the McLean Study of Adult Development. Treatment use was assessed at baseline and at eight two-year follow-up periods with a semistructured interview of proven reliability and validity. RESULTS: Patients with borderline personality disorder reported significantly higher rates of use of 12 of the 16 treatment modalities studied. Only four of the 16 treatment modalities were used by roughly the same percentage of patients with borderline personality disorder and those with other axis II disorders: individual therapy, intensive individual therapy, couples or family therapy, and electroconvulsive therapy. In addition, rates of participation in 13 treatment modalities declined significantly over the first eight years of follow-up for those in both study groups. However, the rates of participation in 15 of 16 treatment modalities did not decline significantly over the second eight years of follow-up for those in either study group. CONCLUSIONS: The results of this study suggest that rates of treatment use by patients with borderline personality disorder decline significantly over the short and medium term. They also suggest that these rates remain stable or fail to decline further over the longer term.

Comparison of affective instability in borderline personality disorder and bipolar disorder using a self-report measure.

BACKGROUND: This study used a new self-report instrument to measure frequency and intensity of nine dimensions of affective instability, as well as the extent to which affective instability was interpersonal, in subjects endorsing elevated features of BPD and bipolar disorder. METHOD: Subjects were 818 students enrolled in a state university. The study used self-report instruments to identify 21 participants with elevated features of mania and 30 subjects with significant BPD features. In addition, subjects completed a new self-report instrument to measure affective instability, the Affective Lability Questionnaire for Borderline Personality Disorder (ALQ-BPD). RESULTS: Aggregate frequency and intensity scores, as well as the total scores on the ALQ-BPD, were significantly higher for subjects with elevated borderline traits than subjects with elevated bipolar traits. Subjects with borderline traits reported significantly more frequent affective shifts on seven of nine dimensions of the ALQ-BPD. Subjects with borderline traits reported significantly more intense affective shifts on two of nine dimensions. Both groups reported affective instability that was less than 50% reactive to interpersonal events, but subjects with borderline traits reported affective instability that was significantly more interpersonal than that reported by subjects with bipolar traits. CONCLUSION: The affective instability associated with symptoms of BPD and bipolar disorder has different profiles, particularly with respect to frequency. Borderline affective instability appears more interpersonal than the affective instability associated with bipolar symptoms.

The course of anxiety disorders other than PTSD in patients with borderline personality disorder and Axis II comparison subjects: a 10-year follow-up study.

The objectives of this study were to assess the rates of comorbid anxiety disorders other than PTSD in patients with borderline personality disorder (BPD) and Axis II comparison subjects over ten years of prospective follow-up and to determine time-to-remission, recurrence, and new onset of these disorders. The SCID I was administered to 290 borderline patients and 72 Axis II comparison subjects at baseline and at five contiguous 2-year follow-up waves. The rates of anxiety disorders for those in both groups declined significantly over time, although they remained significantly higher among borderline patients. By 10-year follow-up, the rates of remission for borderline patients who met criteria for these disorders at baseline were high, while the rates of recurrences and new onsets were moderate. These results suggest that anxiety disorders are very common over time among borderline patients. They also suggest that these disorders have an intermittent course among those with BPD.

Attainment and stability of sustained symptomatic remission and recovery among patients with borderline personality disorder and axis II comparison subjects: a 16-year prospective follow-up study.

OBJECTIVE: The purposes of this study were to determine time to attainment of symptom remission and to recovery lasting 2, 4, 6, or 8 years among patients with borderline personality disorder and comparison subjects with other personality disorders and to determine the stability of these outcomes. METHOD: A total of 290 inpatients with borderline personality disorder and 72 comparison subjects with other axis II disorders were assessed during their index admission using a series of semistructured interviews, which were administered again at eight successive 2-year follow-up sessions. For inclusion in the study, patients with borderline personality disorder had to meet criteria for both the Revised Diagnostic Interview for Borderlines and DSM-III-R. RESULTS: Borderline patients were significantly slower to achieve remission or recovery (which involved good social and vocational functioning as well as symptomatic remission) than axis II comparison subjects. However, by the time of the 16-year follow-up assessment, both groups had achieved similarly high rates of remission (range for borderline patients: 78%-99%; range for axis II comparison subjects: 97%-99%) but not recovery (40%-60% compared with 75%-85%). In contrast, symptomatic recurrence and loss of recovery occurred more rapidly and at substantially higher rates among borderline patients than axis II comparison subjects (recurrence: 10%-36% compared with 4%-7%; loss of recovery: 20%-44% compared with 9%-28%). CONCLUSIONS: Our results suggest that sustained symptomatic remission is substantially more common than sustained recovery from borderline personality disorder and that sustained remissions and recoveries are substantially more difficult for individuals with borderline personality disorder to attain and maintain than for individuals with other forms of personality disorder.

Predictors of suicide attempts in patients with borderline personality disorder over 16 years of prospective follow-up.

BACKGROUND: It is clinically important to understand the factors that increase the likelihood of the frequent and recurrent suicide attempts seen in those with borderline personality disorder (BPD). Although several studies have examined this subject in a cross-sectional manner, the aim of this study was to determine the most clinically relevant baseline and time-varying predictors of suicide attempts over 16 years of prospective follow-up among patients with BPD. METHOD: Two-hundred and ninety in-patients meeting Revised Diagnostic Interview for Borderlines (DIB-R) and DSM-III-R criteria for BPD were assessed during their index admission using a series of semistructured interviews and self-report measures. These subjects were then reassessed using the same instruments every 2 years. The generalized estimating equations (GEE) approach was used to model the odds of suicide attempts in longitudinal analyses, controlling for assessment period, yielding an odds ratio (OR) and 95% confidence interval (CI) for each predictor. RESULTS: Nineteen variables were found to be significant bivariate predictors of suicide attempts. Eight of these, seven of which were time-varying, remained significant in multivariate analyses: diagnosis of major depressive disorder (MDD), substance use disorder (SUD), post-traumatic stress disorder (PTSD), presence of self-harm, adult sexual assault, having a caretaker who has completed suicide, affective instability, and more severe dissociation. CONCLUSIONS: The results of this study suggest that prediction of suicide attempts among borderline patients is complex, involving co-occurring disorders, co-occurring symptoms of BPD (self-harm, affective reactivity and dissociation), adult adversity, and a family history of completed suicide.

Affective lability in bipolar disorder and borderline personality disorder.

BACKGROUND: The boundaries between the affective instability in bipolar disorder and borderline personality disorder have not been clearly defined. Using self-report measures, previous research has suggested that the affective lability of patients with bipolar disorder and borderline personality disorder may have different characteristics. METHODS: We assessed the mood states of 29 subjects meeting Revised Diagnostic Interview for Borderlines and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for BPD and 25 subjects meeting DSM-IV criteria for bipolar II disorder or cyclothymia using the Affective Lability Scale (ALS), the Affect Intensity Measure (AIM), and a newly developed clinician-administered instrument, the Affective Lability Interview for Borderline Personality Disorder (ALI-BPD). The ALI-BPD measures frequency and intensity of shifts in 8 affective dimensions. Subjects in the borderline group could not meet criteria for bipolar disorder; subjects in the bipolar/cyclothymia group could not meet criteria for BPD. RESULTS: Patients in the bipolar group had significantly higher scores on the euthymia-elation subscale of the ALS; patients in the BPD group had significantly higher scores on the anxiety-depression subscale of the ALS. Patients with bipolar disorder had significantly higher total AIM scores and significantly higher score on the AIM positive emotion subscale. In terms of frequency, patients in the borderline group reported the following: (1) significantly less frequent affective shifts between euthymia-elation and depression-elation on the ALI-BPD and (2) significantly more frequent shifts between euthymia-anger, anxiety-depression, and depression-anxiety. In terms of intensity, borderline patients reported the following: (1) significantly less intense shifts between euthymia-elation and depression-elation on the ALI-BPD and (2) significantly more intense shifts between euthymia-anxiety, euthymia-anger, anxiety-depression, and depression-anxiety. CONCLUSION: The affective lability of patients with borderline and bipolar II/cyclothymic can be differentiated with respect to frequency and intensity using both self-report and clinician-administered measures.

The course of substance use disorders in patients with borderline personality disorder and Axis II comparison subjects: a 10-year follow-up study.

AIM: The purpose of this study is to detail the course of substance use disorders (SUDs) over 10 years of prospective follow-up among patients with borderline personality disorder (BPD) and Axis II comparison subjects. DESIGN: This study uses data from the McLean Study of Adult Development (MSAD), a multi-faceted study of the longitudinal course of BPD using reliable repeated measures administered every 2 years over a decade of prospective follow-up. SETTING: All subjects were initially in-patients at McLean Hospital in Belmont Massachusetts. PARTICIPANTS; A total of 290 patients with BPD and 72 Axis II comparison subjects were assessed at baseline and five waves of follow-up. MEASUREMENTS: The Structured Clinical Interview for DSM-III-R Axis I Disorders (SCID-I), the Revised Diagnostic Interview for Borderlines (DIB-R) and the Diagnostic Interview for DSM-III-R Personality Disorders (DIPD-R) were administered six times. Generalized estimating equations were used to assess longitudinal prevalence of SUDs. Kaplan-Meier analyses were used to assess time-to-remission, recurrence and new onsets of SUDs. RESULTS: The prevalence of SUDs among borderline patients and Axis II comparison subjects declined significantly over time, while remaining significantly more common among those with BPD. More than 90% of borderline patients meeting criteria for a SUD at baseline experienced a remission by 10-year follow-up. Recurrences and new onsets of SUDs were less common (35-40% and 21-23%). CONCLUSIONS: Remissions of alcohol and drug abuse/dependence among borderline patients are both common and relatively stable. Results also suggest that new onsets of these disorders are less common than might be expected.

Predictors of self-mutilation in patients with borderline personality disorder: A 10-year follow-up study.

BACKGROUND: Self-mutilation is a common and serious problem in patients with borderline personality disorder (BPD). The purpose of this study was to determine the most clinically relevant baseline and time-varying predictors of self-mutilation over 10 years of prospective follow-up among patients with BPD. METHOD: Four semistructured interviews assessing axis I disorders, childhood adversity, adult experiences of abuse, and experiences of self-mutilation were administered at baseline to 290 patients meeting DIB-R and DSM-III-R criteria for BPD. Three of these interviews (all except for the childhood adversity interview) and two self-report measures pertaining to dysphoric affects and cognitions were administered at each of five contiguous two-year follow-up periods. RESULTS: Eleven variables were found to be significant bivariate predictors of self-mutilation over the five follow-up periods. Six of these predictors remained significant in multivariate analyses: female gender, severity of dysphoric cognitions (mostly overvalued ideas), severity of dissociative symptoms, major depression, history of childhood sexual abuse, and sexual assaults as an adult. CONCLUSIONS: Taken together, the results of this study suggest that factors pertaining to traumatic experiences throughout the lifespan are significant risk factors for self-mutilation over time. These results also suggest that major depressive episodes and cognitive symptoms, particularly overvalued ideas and dissociation, significantly heighten the risk of self-injurious behaviors tracked for a decade.

Ten-year use of mental health services by patients with borderline personality disorder and with other axis II disorders.

OBJECTIVE: The study determined the prevalence of use of three treatment modalities (individual therapy, medication, and hospitalization) reported over a ten-year period by patients with borderline personality disorder and by those in a comparison group with other axis II disorders. Time to cessation and time to resumption for each modality among patients with borderline personality disorder were also determined. METHODS: Treatment history of inpatients with a reliable diagnosis of borderline personality disorder (N=290) and of other axis II disorders (N=72) was assessed with an interview of proven reliability during the index admission. Treatment history was reassessed at two-year intervals for ten years. RESULTS: For all three treatment modalities, prevalence of use declined significantly among patients with borderline personality disorder and among those in the comparison group. Among patients with borderline personality disorder, 52% reported having stopped individual therapy and 44% reported having stopped medication at one or more of the follow-up interviews over ten years. However, 85% of those who had stopped psychotherapy and 67% of those who stopped taking medication resumed these treatments during a subsequent two-year period. In contrast, 88% had experienced at least one two-year period without a psychiatric hospitalization by the time of the ten-year follow-up; however, almost half of these patients were subsequently rehospitalized. CONCLUSIONS: The results suggest that patients with borderline personality disorder tend to use outpatient treatments without interruption over prolonged periods. They also suggest that inpatient treatment is used far more intermittently by patients with borderline personality disorder.

A longitudinal study of the 10-year course of interpersonal features in borderline personality disorder.

The literature on borderline personality disorder (BPD) describes interpersonal disturbances as a core sector of psychopathology. The longitudinal course of these features remains poorly understood. Our aim is to describe the course of interpersonal features of BPD in a more detailed way than has been done previously. Twenty interpersonal aspects of borderline psychopathology were assessed using two reliable semi-structured diagnostic interviews at baseline and at five successive two-year follow-up waves in the ongoing McLean Study for Adult Development. Behaviorally-oriented features, such as recurrent breakups, sadism, demandingness, entitlement, regression in treatment, and boundary violations, remitted quickly and were rare at the end of follow-up. The interpersonal features slowest to remit were affective responses to being alone, active caretaking, discomfort with care, and dependency. The behavioral interpersonal features of BPD remit rapidly, while core affectively-oriented features related to intolerance of aloneness and conflicts over dependency are more persistent.

Time to attainment of recovery from borderline personality disorder and stability of recovery: A 10-year prospective follow-up study.

OBJECTIVE: The purposes of this study were to determine time to attainment of recovery from borderline personality disorder and to assess the stability of recovery. METHOD: A total of 290 inpatients who met both DSM-III-R and Revised Diagnostic Interview for Borderlines criteria for borderline personality disorder were assessed during their index admission using a series of semistructured interviews and self-report measures. The same instruments were readministered every 2 years for 10 years. RESULTS: Over the study period, 50% of participants achieved recovery from borderline personality disorder, which was defined as remission of symptoms and having good social and vocational functioning during the previous 2 years. Overall, 93% of participants attained a remission of symptoms lasting at least 2 years, and 86% attained a sustained remission lasting at least 4 years. Of those who achieved recovery, 34% lost their recovery. Of those who achieved a 2-year remission of symptoms, 30% had a symptomatic recurrence, and of those who achieved a sustained remission, only 15% experienced a recurrence. CONCLUSIONS: Taken together, the results of this study suggest that recovery from borderline personality disorder, with both symptomatic remission and good psychosocial functioning, seems difficult for many patients to attain. The results also suggest that once attained, such a recovery is relatively stable over time.

The 10-year course of psychosocial functioning among patients with borderline personality disorder and axis II comparison subjects.

OBJECTIVE: The purpose of this study was to determine the 10-year course of the psychosocial functioning of patients with borderline personality disorder (BPD). METHOD: The social and vocational functioning of 290 inpatients meeting both the Revised Diagnostic Interview for Borderlines (DIB-R) and DSM-III-R criteria for BPD and 72 axis II comparison subjects were carefully assessed during their index admission. Psychosocial functioning was reassessed using similar methods at five contiguous 2-year time periods. RESULTS: Borderline patients without good psychosocial functioning at baseline reported difficulty attaining it for the first time. Those who had such functioning at baseline reported difficulty retaining and then regaining it. In addition, over 90% of their poor psychosocial functioning was due to poor vocational but not social performance. CONCLUSION: Good psychosocial functioning that involves both social and vocational competence is difficult for borderline patients to achieve and maintain over time. In addition, their vocational functioning is substantially more compromised than their social functioning.

The course of eating disorders in patients with borderline personality disorder: a 10-year follow-up study.

OBJECTIVE: The purpose of this study was to describe the longitudinal course of eating disorders in patients with borderline personality disorder. METHOD: The SCID I was administered to 290 borderline inpatients and 72 participants with other axis II disorders during their index admission and at five contiguous 2-year follow-up periods. RESULTS: The prevalence of anorexia, bulimia, and eating disorder not otherwise specified (EDNOS) declined significantly over time for those in both study groups but the prevalence of EDNOS remained significantly higher among borderline patients. While over 90% of borderline patients meeting criteria for anorexia, bulimia, or EDNOS at baseline experienced a stable remission by the time of the 10-year follow-up, diagnostic migration was common, particularly for those with anorexia or bulimia. In addition, both recurrences (52%) and new onsets (43%) of EDNOS were more common among borderline patients than recurrences and new onsets of anorexia (28% and 4%) and bulimia (29% and 11%). DISCUSSION: The results of this study suggest that the prognosis for both anorexia and bulimia in borderline patients is complicated, with remissions being stable but migrations to other eating disorders being common. The results also suggest that EDNOS may be the most prevalent and enduring of the eating disorders in these patients.